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Ann Thorac Surg 2004;78:753-754
© 2004 The Society of Thoracic Surgeons
Department of Surgery II, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
e-mail: ohsaki{at}saiseikai-hp.chuo.fukuoka.jp
To the Editor:
We are grateful to Dr Pramesh and colleagues for their comments on our article [1] describing the prognostic implications of surgically resected T4 non–small-cell lung cancer (NSCLC), according to the subgroups of T4 category, nodal status, and resection completeness. The main objective of this study was to propose subgroups of T4 NSCLC as a guide for selecting the patients who may benefit from aggressive surgical resection. Stage IIIB is usually defined as unresectable disease; however, there may be different biologic behaviors between patients with local T4 disease and those with N2 or N3 nodal disease within the stage IIIB classification, and some of the local T4 disease may be suitable for aggressive surgical resection. Our results suggest that T4 N0–1 disease without pleural disease may be amenable to surgical cure.
As indicated, this study consisted of carefully selected patients with T4 NSCLC. It would be very useful to know how many T4 NSCLC patients in total were treated, that is, the denominator of all T4 patients from which the surgical series was selected. If this were available, then it might yield further enlightening information concerning the selection criteria for aggressive surgery. In fact, many T4 patients in our department received nonoperative treatments or supportive care alone, although we do not know the exact number of such patients.
Given the poor results of patients resected for T4 N2 NSCLC, mediastinoscopy is a critical preoperative assessment for excluding patients with occult N2 disease that would have negligible benefits from aggressive surgical therapy. As recommended, induction chemotherapy may be useful for patients with T4 N2 disease; however, it does not seem reasonable to discuss the potential role of induction chemotherapy for local T4 disease together with N2 nodal disease, because of the differences in their biologic behaviors. Definitive conclusions concerning induction chemotherapy, even for T1–3 N2 disease, await further study maturation. We fully agree with Dr Pramesh and colleagues that the screening for occult distant metastases or occult pleural dissemination, including positron emission tomography imaging and intraoperative pleural lavage cytology, is necessary for patients with T4 disease to exclude those who would not benefit from aggressive surgical resection.
Therapeutic guidelines for T4 NSCLC, including the potential of aggressive surgical approaches for patients with tumors invading the mediastinal organs, are still an investigational issue; however, a systematic review based on more studies may confirm that extended surgery for some patients within this category is worthwhile.
References
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